Question 10: How is elevated IOP managed in pigmentary glaucoma?

Question 10: How is elevated IOP managed in pigmentary glaucoma?

Answer:

Pigmentary glaucoma is treated the same way as other glaucomas, in that the primary aim of management is to reduce IOP to a level that halts or reduces damage to the optic nerve. During the active phases of pigment release, treatment may need to be more aggressive.

In the setting of diminished aqueous drainage via the trabecular meshwork pathway, prostaglandin analogues are a first-line medical therapy as they reduce IOP by increasing uveoscleral outflow. Increased iris pigmentation can occur with topical prostaglandin therapy. However, this does not lead to an increase in pigment dispersion as the iris stromal melanocytes are affected, not the iris pigmented epithelium.

Theoretically, miotic agents, including pilocarpine, are the ideal therapy for pigmentary glaucoma as they lower IOP, prevent pupil dilation and reduce posterior iris bowing. However, the side effect profile, particularly in young patients, is poor and adverse effects include accommodative spasm, increased risk of retinal detachment and cataract formation. They are therefore not used as a primary treatment in pigmentary glaucoma.

Alpha adrenergic agonists, beta adrenergic antagonists and carbonic anhydrase inhibitors may all be used in the treatment of pigmentary glaucoma, provided there are no contraindications to these agents.

Argon laser trabeculoplasty and selective laser trabeculoplasty have been shown to be effective in the treatment of patients with pigmentary glaucoma. There have been reports of markedly elevated IOP post selective laser trabeculoplasty in eyes with pigmentary glaucoma, so close post-laser observation is advised.

Some patients may require trabeculectomy surgery to control pigmentary glaucoma. In these patients, pigment deposition may be noted within the filtering bleb, however, it is not known whether this adversely affects the function of the trabeculectomy.

End of answer